[PHNUTR-L] Diagnosis: Conflict of Interest

[Kathrynne Holden]

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Diagnosis: Conflict of Interest
By DANIEL CARLAT
Boston

http://www.nytimes.com/2007/06/13/opinion/13carlat.html?_r=2&oref=slogin&oref=slogin


THE revelation that the diabetes drug Avandia can potentially cause 
heart disease is the latest in a string of pharmaceutical 
disappointments. Vioxx was pulled from the market in 2004 because it 
doubled the risks for heart attacks and strokes. Eli Lilly recently paid 
$750 million to settle lawsuits alleging that Zyprexa causes diabetes. 
Many have criticized the Food and Drug Administration as being too lax 
about monitoring drug safety.

While those criticisms have merit, there is another culprit: the 
transformation of continuing medical education into an enterprise for 
drug marketing. The chore of teaching doctors how to practice medicine 
has been handed to the pharmaceutical industry. As a result, dangerous 
side effects are rarely on the curriculum.

Most states require that doctors obtain a minimum number of credit hours 
of continuing medical education each year to maintain their medical 
licenses. Not so long ago, most of these courses were produced and paid 
for by universities and medical associations. But this has changed 
drastically over the past decade.

According to the most recent data available from the national 
organization in charge of accrediting the courses, drug-industry 
financing of continuing medical education has nearly quadrupled since 
1998, from $302 million to $1.12 billion. Half of all continuing medical 
education courses in the United States are now paid for by drug 
companies, up from a third a decade ago. Because pharmaceutical 
companies now set much of the agenda for what doctors learn about drugs, 
crucial information about potential drug dangers is played down, to the 
detriment of patient care.

For example, GlaxoSmithKline footed the bill for dozens of educational 
courses intended to emphasize the benefits of Avandia over other drugs. 
An influential Internet-based educational program paid for by the 
company focused on specific studies that highlighted Avandia’s 
advantages without discussing one of the drug’s most worrisome side 
effects, increased levels of the lipids implicated in heart disease.

Avandia’s chief competitor, a drug from Takeda Pharmaceuticals called 
Actos, improves lipid levels but was hardly mentioned. When 
GlaxoSmithKline’s program did cite Actos, it did so tepidly. The 
information in the course was presented by noted diabetes academics paid 
by GlaxoSmithKline and other drug companies.

GlaxoSmithKline is not the only offender. The major organizations in 
diabetes education, like the National Diabetes Education Initiative, 
offer dozens of continuing medical education courses on diabetes that 
are free to doctors and paid for by drug companies. Predictably, each 
course focuses on the advantages of the sponsor’s product and minimizes 
discussion of dangerous side effects.

Education that doubles as advertising for drug companies occurs in all 
branches of medicine. Merck promoted Vioxx for arthritis by using 
programs for continuing medical education, which helped contribute to 
the more than 100 million prescriptions of the drug before it was pulled 
from the market.

According to Dr. David Graham, a safety researcher for the Food and Drug 
Administration, Vioxx was responsible for up to 140,000 cases of serious 
heart disease from 1999 until 2004, when it was withdrawn. But the 
potential cardiac dangers of Vioxx were played down in the courses paid 
for by Merck. In one instance, the company canceled lectures it had 
sponsored by a Stanford researcher who had mentioned, in talks to 
doctors, the cardiac risks from taking Vioxx.

Drug companies should never have been allowed to become the primary 
educator for America’s doctors. The Accreditation Council for Continuing 
Medical Education, a nonprofit organization composed of the major 
medical associations, establishes the rules that govern continuing 
medical education. According to the guidelines, companies are forbidden 
from directly paying doctors who teach continuing medical education courses.

But the standards have a loophole that allows drug companies to 
circumvent the regulations. They hire for-profit “medical education 
communication companies” to organize the courses. These companies 
receive millions of dollars from drug companies to create course work 
and to pay doctors to deliver the content. Sometimes, they pay doctors 
to give lectures to other doctors. Other times, prominent doctors are 
paid to be listed as the authors of journal articles that are written by 
ghost writers, a practice that was extensively documented in court 
records from a lawsuit against Pfizer.

Either way, the content is rarely developed by the identified experts. 
Instead, it is developed by the undisclosed communication company, which 
is paid by the sponsoring pharmaceutical company.

Essentially, this is a new twist on that well-known instrument of 
corruption, money laundering. Drug companies don’t directly pay doctors 
to teach courses. Instead, they pay someone else to cut the checks. 
Similarly, the drug companies don’t explicitly tell doctors to say good 
things about their products. Instead, they hire a company to write good 
things about their products and to pay doctors to deliver the messages.

These shenanigans were recently spotlighted by Senator Max Baucus, 
Democrat of Montana, and Senator Charles Grassley, Republican of Iowa, 
of the Senate Finance Committee. In April, their committee released a 
report, two years in the making, concluding that drug companies have 
used educational grants unethically as a way of marketing their products.

In response, the guidelines regarding commercial support for continuing 
medical education are being reviewed. The solution could hardly be 
simpler: any continuing medical education that is paid for by the drug 
industry should not be accredited. Drug companies could still pay for 
any educational event, article or pamphlet they choose, but their 
courses and materials would no longer bear the imprimatur and implied 
credibility of accreditation.

Doctors, in turn, would be encouraged to seek medical education from 
sources that are not financed by drug companies. A renewed commitment to 
unbiased education would allow doctors to learn about drug risks sooner. 
This would be good for doctors, and even better for their patients.

Daniel Carlat, a professor at Tufts Medical School, is the editor in 
chief of The Carlat Psychiatry Report.
-- 
Kathrynne Holden, MS, RD < fivestar at nutritionucanlivewith.com >
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